I have been told by a person I trust to have factual information that about 60% of US births are delivered by C-section. While I trust this person, this is still a factoid that I have no other source for, and I’ll ask the question here - Is the information accurate?
Second, I know from the Norwegian Central Bureau of Statistics (link in Norwegian) that the rate of births delivered by C-section was approximately 14% during the '90’s. So my second question would be, why the difference? I cannot think of a medical reason why Americans would need that many more C-sections, but IANA doctor, so there might very well be some. (I have other speculations, but they’re just that - speculations - and therefore not fit for this forum, correct?)
I recently (2 months ago) had a baby and during my pregnancy this topic came up on a message board on which I am a member. The 60% figure was quoted extensively and reasons given were varied and included convenience on the part of mother and doctor and also the fact that doctors in the US are a lot quicker to jump to do a c-section at the first sign of trouble due to litigation if anything were to go wrong in a natural birth. It was also noted that in a lot of other countries, (don’t know whether this is true in Norway), women tend to use midwives rather than OB/GYNs for births unless there is a specific problem and midwives generally tend towards more natural births. Another thing that was brought up was the frequency of induced births (with their attending problems that encourage c-section) as well as the use of epidurals which, under certain circumstances, encourage a higher rate of c-section too.
When I was having my kids in the early 1990s the statistic was cited as 25% of all births in the U.S. were C-section. Are you *sure * it’s up to 60% now? That sounds incredibly high.
It cannot possibly be true that 60% of all deliveries are done surgically, but think about it: 26.1% of all births are surgical. However, if a woman has had a previous c/s, in a great many regions now she has ZERO opportunity to attempt vaginal birth unless she simply stays home and takes her chances (with or without a trained attendant) - the hospitals won’t allow it for liability (not safety) reasons. So, in those regions, 100% of all women with previous c/s deliveries will now have c/s deliveries, PLUS whatever the percentage is of primaparas who get cut…and a few years later, when those primaparas go back as multiparas, they’re going to get cut too.
The percentage of women who have had, or will have had one or more c/s deliveries by the end of their childbearing careers is surely higher than 26%. That number may be as high as 60%.
I also find it hard to believe that the figure could have risen by that much, but Chotii brings up a good point. This might have been the figure that my source referred to, but she certainly presented it as a percentage of all birhts. And Girl Next Door - no, I’m not sure. I asked the question, didn’t I?
Anyway, my source cited her references as:
I don’t have access to these books.
biddee, I don’t know how many people use midwives; but most if not close to all babies are delivered at a hospital.
A possible reason I thought about was that the way the health care system works in the US, the hospital/doctor would get paid more for a C-section, as well. Is this accurate (the higher amount of money)?
Are you sure that was the US rate? I think that is the rate in Argentina, where elective c-sections are commonly done (some hospitals have rates as high as 80% or more). Even if you include the repeat-c and VBAC repeaters in the number, I don’t think you will get as high as 60% of mothers having had one or more birth by c-section. Partly because the odds of a c-section for non-first timers goes down.
Most births in the US are also in hospitals, and IIRC, fewer than 10% are attended by midwives, and less than 1% are outside hospitals. You can search the CDC wonderdata archive for specifics if you want to, or the US Vital Stats.
The reasons for the difference are not well defined, scientifically speaking. But they are speculated to include (in probably highest-impact to lowest-impact order, IMHO):
Litigation against OBs for non-action is really high. The attitude is that if something goes wrong in an OB-attended birth, it is because the OB failed to do something, somehow. So OBs are pushed by medicolegal issues toward more interventions if there is ANY risk, even if the risk is not well defined, and even if the action is associated with little or no benefits in evidence-based medical research, and even if the action carries known risks… known risks (such as those that come with c-section) are less likely to trigger litigation because of the informed consent process, as well - unknown risks are what people sue over.
Increased maternal age for first birth. The older a woman is, the more likely there will be a c-section for the birth. Whether this is due to real factors (less flexibility in the ligaments, for example), or ageism (less expectation that older women can do it, aside from real factors), who knows. For women under 19 years with a first birth, the c-section rate in the US in 2001 was 14%. For women over 35 with a first birth, it was 36%. Start increasing the numbers of women who are older having babies, and the stat is going to skew upwards. Given the numbers of women who are having their first baby at over 30, that’s a big part of the picture.
VBAC vs. Repeat C-section rate. In 2001, 82% of births with a prior c-section were also c-section. That was a 5% increase from the year before, and from what I’ve heard it has continued to climb (at least locally). VBAC is now not allowed in many hospitals, even if you are low risk comparitively speaking. Native American populations have the highest VBAC rate of all groups (by about 3%), and from the research I’ve read on the Navajo experiences, that may be partly due to a very positive and active/supportive birth culture, plus low access to hospitals with intervention capabilities. If you don’t have much choice… Interestingly, back in 1998 or so, I was looking at my state’s Vital Stats, and they showed that of women attempting a vaginal birth after c-section, more acheived it than women having a vaginal first birth (the rate was about 78% successful for attempted VBAC, IIRC). Most don’t attempt it, however.
Birth culture in the US. The US birth culture is one of ‘it is going to hurt, and you can’t do anything about it, so ask for help!’ - which is one part true, and one part misleading. The lack of control of the process (IMHO) is interpreted to mean a lack of influence on the process. Many women are fed so many nightmare stories, they’re set up to be terrified, lack knowledge, and lack support. Doulas (female professional or amateur labor support throughout labor) are still rare, even though the Cochrane Medical Abstracts show that they dramatically reduce rates of interventions, perceived pain level, duration of labor, and c-section rate. Approaches to birth range from ‘please don’t let me suffer, I’ll do anything’ to ‘I’m open-minded and will decide at the time about pain meds, but I haven’t bothered to practice any alternative methods of pain management’ to ‘women have been doing it forever, I can can, too (but again, not actually trying to figure out and prepare for how)’ to ‘open minded but prepared and practiced for natural’ to ‘I’ll do anything to avoid drugs, and will feel like a bad mom if I accept or need any’. There are only two of those that ‘work’ in the field, IMHO - ‘please don’t let me suffer’ and ‘open minded but prepared’… and the relative numbers of each are pretty skewed toward the meds-prefering side. For women who walk in the door expecting to have their experience managed for them, the odds of a c-section are much higher. Why their expectations make that much difference is unclear, but the studies on the Navajo again indicate that the birth culture, support system, and value given to a natural vaginal birth (high) are major factors in their low c-section rate. Plus, women who want meds options are more likely to select care locations that have all the range available, and the availability tends to fill in the difference between waiting just a little longer to see if a vaginal birth is possible (because transferring to another location is a major pain in the butt), or just going for the c-section ‘now’. That can make a significant statistical difference.
Increasing rates of elective induction of labor. I can’t recall the last stat I saw on that, but it stunned me. There is one practice near us that has an over-80% 38-week induction rate. That is, they induce nearly everyone at 38 weeks! They have a high c-section rate, as well, since they don’t apparently use a Bishops Score to schedule inductions by (low score increases c-section rates). Any time a population-based induction rate goes up, the odds that you’ll be inducing more women with low Bishops goes up, and the c-section risk goes up.
Maybe money. Hospitals get more money for c-sections, and some doctors charge more for c-sections than vaginal births (not all do, though - I know at least one who charges the same for ANY birth, because they average out to the same amount of time per delivery). But if that’s a factor, it is at the far subconscious level for most OBs. Even the nit OB I got (on call) with my most recent birth wasn’t thinking about money. She was thinking about risk, fear, lawsuits (she even commented to my midwife that she was afraid we’d sue her for trying to scare me into a c-section - but she’d also clearly been scared that something MIGHT go wrong, and a c-section was her only way to prevent that PARTICULAR thing from going wrong, even if other things might go wrong as a result of the surgery… and no, she didn’t convince me, and she admitted she was wrong, too.). I highly doubt that most doctors in the moment of deciding what to do about a particular birth, are thinking ‘hmm, which is gonna pay me more?’ Maybe some do, but not most. Hospital policies may lean more toward supporting c-sections with money issues included, but again, it seems less likely than that they are trying to avoid litigation, which is far more costly when they lose a case (or even just defending it, or paying increased malpractice rates) than the gains they’d get by doing a few more c-sections a year.
I hope that helps explain somewhat. I don’t know where the 60% number comes from, but I’d be surprised if it was that high. I’d bet closer to 30-35, even if the numbers have continued to climb, which I suspect they have (due to the reduced enthusiasm for VBACs).
Interesting side note. My wife’s first child was by C-section. When our son was due, the ob-gyn was all for VBAC provided that the previous C-section was performed a certain way. Apparently some doctors cut the across the abdominal muscles, rather than parallel to them. If they cross-cut, you’re out of luck. We were in luck.
The other factor is of course the baby’s co-operation. In our case, he wouldn’t drop down into proper position, so we ended up C-sectioning anyway.
BwanaBob, I think you are referring to a horizontal incision in the uterus being okay, and a vertical not being okay, correct? (the abdominal muscles aren’t an issue - it is the uterine muscle that is at issue - I know of women with vertical abdominal incisions who had horizontal uterine incisions…)
There are a lot of factors that influence whether a VBAC is a good option, including incision type (prefering horizontal), time between pregnancies (prefering 2 years gap), degree of tearing of the uterus (if any) the previous time, single-layer suture style vs. double layer (more people are doing singles, but there’s concern that they’re seeing more windowing in repeat c’s if the previous was single-layer), plus issues of placenta position/accretion and baby’s position during labor. Plus induction is now considered to be RIGHT OUT for most care providers. Way bigger risk of rupture if you over-stimulate the uterus by accident.
One of the major risks of c-section that has only been identified in the last few months is increased risk of stillbirth for subsequent babies. Because there’s twice the risk of an unexplained stillbirth before 39 weeks, (not to mention the increased risk of stillbirth for known reasons like placental accretia), the odds of more women opting for an early (pre-39-week)elective repeat c-section are probably going to go up. (I’d hope that the odds of elective initial c-section would go down because of that risk, but because I haven’t seen that stat anywhere ‘public’, I suspect it isn’t hitting visible enough to make much difference to the rates).
In an era when “evidence-based medicine” supposedly reigns, “birth culture” can dictate the birth-related medical practices in the US more than scientific/medical truth. For those interested, I agree that the Cochrane Reviews are a treasure trove of evidence around significant portions of obstetric practice.
The birth culture I refer to is the societal expectation that all desired pregnancies result in perfect children. Although it is never possible to guarantee a perfect outcome in the birth arena, the medicalization of the birth process is the direct result of that societal expectation, and rising C-section rates reflect this (although I don’t have the stats from the past two years, nationally the rate in the US is probably holding currently below 30%).
Consider the following additions to this discussion. It has never been shown that continuous fetal monitoring confers a better outcome than intermittant monitoring in low risk labor situations, yet continuous monitoring is practiced so widely in hospitals that you would think that it was based on indisputable medical evidence. C-sections happen when there is evidence of fetal distress on the monitor; many times the infants delivered in these circumstances show no evidence of distress at birth. But, what if the C-section wasn’t done, labor had continued, and there was a tragic outcome? No way of ever quantifying that hence C-sections will continue to be done for non-reassuring fetal heart tracings. Although rare, uterine rupture during a VBAC (trial of labor) can have devastating consequences for mother and fetus alike. Initial enthusiasm for trials of labor after cesarean, after years of “once a section always a section”, has been tempered in the past few years with newer evidence that there are a subset of women in whom VBAC is truly more risky. In the 80’s, it was considered safe to schedule post-dates inductions up to 43 wks gestational age. Now inductions are being done earlier and earlier because of the evidence that waiting that long significantly increases the possibility of stillbirth. Stillbirths are devastating beyond belief, so our desire to prevent this ghastly outcome results in inductions being done at earlier gestational ages - and as pointed out by Hedra, induction with an unfavorable cervix increases the chances of the ultimate need for C-section.
Medical practice, of any kind, comes with no guarantees. Most medical professionals want to provide birthing women and their families with the best care that is known by the best evidence, but the best evidence may not be known. Women want and deserve control over the birth experience, their providers want control over the medical circumstances that they can control - the irony is that while both patient and provider want the same thing, healthy moms and babies, the desire to control in order to insure this is the very thing that can produce adversarial relationships, unrealistic expectations, and shattered hopes. Talk to your birth providers before you are in labor, whether they be midwife, family physician or obstetrician. Share your preferences, your fears, and ask for a collaborative approach. Ask many questions, demand to know the available medical evidence and justification for any approach that your provider suggests. It is Ok to hope for, but please don’t expect, a perfect outcome. When it is perfect, count your blessings!
One more thing; IME, although it does happen, most doctors who do surgical deliveries do not chose to perform C-sections because it makes them more money. And finally, to all women who have needed to have C-sections, please don’t think of this as a birth failure.
I agree. If a woman has NEEDED a cesarean, it isn’t a failure.
But it can still feel like a failure, at so deep a level that to say ‘you shouldn’t feel that way’ is insulting and condescending. You feel what you feel. Logic has no place.
And this still doesn’t address the question of women (like me) who were mismanaged and/or bullied into cesareans, women who were wheeled into surgery screaming “I DO NOT CONSENT!” and cut anyway, women who were cut without anaesthesia and told “You don’t feel that, it’s just pressure,” women who wanted lots of children but cannot bear the idea of getting pregnant again, because they know they have no option but to go under the knife for every future child because of a past c/s, women who get pregnant after a past c/s, and spend their entire pregnancy in an emotional state of absolute distress because they have “no choice” but to go under the knife because their hospital “won’t allow” cesarean due to a one size fits all policy…and a medical profession that dismisses all of this as irrelevent, patronizing, “we know what’s best for you, and what you feel doesn’t matter because at least you have a healthy baby.”
When the medical profession starts to actually acknowledge that this is a problem, then maybe we’ll make some progress.
IANA doctor, but my wife has delivered two children by C-section, so I can offer you our reasoning, FWIW. The first child would not come out, plain and simple, after 12+ hours of labor (sans epidural). One can talk about birth weight, pelvis dimensions, mother’s size, etc., but our daughter would not fit. After the surgery, my wife was exhausted, having gone through all the effort of an attempted delivery and then the trauma of surgery. When we were expecting our second child, with the agreement of our pediatrician we opted to avoid the chance of a repeat scenario and schedule a C-section. It turns out that our younger daughter was quite a bit smaller than our elder, but given the information available at the time, this feels like the right decision. In both cases, recovery was very quick and mother & child were healthy.
In the run-up to both births, it seems like there is almost a stigma against C-sections, and particularly against medical aids like epidurals; at least this was the perception I got in the birthing classes, and I think is also echoed to some extent in some of the (certainly well-informed) opinions in this thread. In our case, if we had access to primitive health care only, then the second C-section would not have been an option, since the first birth would likely have been fatal.
I do understand that this discussion is about larger trends and issues than the experiences of a single family, so I hope that you’ll take these few short sentences as our personal experience only. Thanks.
My deepest apologies for unintentionally implying that any woman’s emotions about their birth experience are not valid. Your experience sounds absolutely horrendous. My intention was actually a plea to reject a part of our current birth culture that pressures some woman to believe that they have failed if somehow they weren’t able to have a vaginal birth, that it was their fault, or were somehow weaker… IMHO, having this pressure only seems to add to an already traumatic experience.
Also agree that the medical profession has significant healing within it’s own ranks that must occur before medicine can truly be re-humanized.
There’s more to it than that, though. For if the only objective was a perfect birth, then one would expect the U.S. to adopt the techniques used in countries with less infant mortality. Most of the countries with better infant mortality statistics do things a lot differently than we do. Yes there is almost no effort made to emulate what they are doing.
Along with the perfect outcome fantasy, in the U.S. you have to mix in:
The deification of technology. The more high tech, the better. Continuous fetal monitoring is an example - it hasn’t been examined rigorously because it’s practically unthinkable to suggest that more technology could result in a worse outcome.
The U.S. propensity to avoid responsibility and cupability. The vast majority of American women appear to be very satisified with the current set up. For the most part they are held blameless no matter what they do when they are pregnant while the OB is punished for every real or imagined omission or comission.
The impersonality and adversarial nature of most interactions in hospitals. Doctors are trained to lie rather than admit error. Women are often shut up, rushed along and treated like idiot 3 year olds. Lots of studies have shown that key to reduing litigation is to improve communication and, for lack of a better term, bedside manner. In contrast, just about all the people I know who have been discharged from a hospital are so pissed off they almost hope something goes wrong so that they can sue the S.O.B.'s. Lots do - which keeps the litigation-mistrust-over intervene cycle going.
The American suspicion of and lack of support for preventative (i.e. socialized) medicine and always go for the compelling single story vs. boring epidemiology. Other countries might spend 3 million of their health care budget to improve prenatal care for 100,000 women and this might improve birth outcomes in, say, 100 babies. In this country, those 100,000 women have been demonized as welfare parasites. We take that 3 million and use it to save one baby that needs pre-natal surgery and then months in the NICU. At the end of the day - Other country has saved 100 babies, US has saved 1.
